Succession Planning for the Neonatal Advanced Practice Nurse

The scope for neonatal advanced practice registered nurses (APRNs) has evolved over time and with the growth of health care. The role of the neonatal nurse practitioner (NNP), for example, has expanded beyond the population of infants within a neonatal intensive care unit to include infants who have chronic conditions as a result of premature birth or neonatal pathophysiology. Practice environments include all levels of inpatient care, neonatal transport, delivery room management, and academic, outpatient, and community-based settings. The role of the NPP spans the continuum from acute to chronic to primary care, depending upon the setting. The NNP and neonatal clinical nurse specialist integrate research, education, practice, and management for a specific population. Both use advanced assessment skills, critical thinking, diagnostic reasoning, and clinical competence to advance population health. The nature of the APRN’s work depends upon the needs of the institution or practice environment. The purpose of this column is to explore current barriers to the creation of NNPs and to discuss how succession planning can limit the knowledge gap as experienced NNPs leave the workforce.Historically, the supply of NNPs has not met the demand for services, although the demand varies by region of the country.1 In 2016, The National Association of Neonatal Nurses surveyed the NNP workforce.2 NNPs (n = 5433) were surveyed over a 14-day period in September and October of 2016. There were 1100 responses representing primary practice locations in all 11 regions represented by the American Association of Nurse Practitioners. Seventy-three percent of NNPs acting in administrative roles responded that they did not have enough NNP staff to cover their needs. Factors contributing to these shortages included lack of qualified candidates, lack of a budget, vacancies or unfilled positions, the salary offered, the practice location, and the lack of perceived need for the role by other team members.2Changes, including restricted resident time in neonatal intensive care units for graduate medical students and pediatric residents, have also increased the NNP workforce demand. When asked who was filling NNP vacancies, responders reported the following results: 40% of positions were left vacant, 28% were filled by a neonatologist, 23% were filled by other types of APRNs, 20% were filled by physician assistants, 13% were filled by hospitalists, 3% were filled by intensivists, and 8% were filled by other types of health care providers.2The National Association of Neonatal Nurses and the National Association of Neonatal Nurse Practitioners monitor aspects of advanced practice neonatal nursing over time. As of January 11, 2018, there were a reported 5903 NNPs, with 5824 in the United States, 4 in the armed forces, and 75 in Canada. There are 39 active NNP programs in the United States, which produced an average of 266 graduates per year3 from 2008 through 2016. This number is not expected to keep up with future demand.4–6 In 2013 there were only 6 programs in the United States that specifically prepared neonatal clinical nurse specialists.1In the fall of 2010, the US Department of Education changed program regulations for higher education. The changes included redefined credit hours and creation of state-authorized regulations. These regulations created barriers for higher education that occurs via distance learning by making it more difficult and expensive for institutions of higher learning to operate across state lines. Many institutions will not enroll students from institutions that have more than one location, students who took coursework from another institution in another state, or students who completed internships or externships at locations not recognized by the Department of Education.1 The new regulations have created hardship for students by forcing them to relocate to attend programs, and this has resulted in decreased program enrollments.1 This change has caused difficulties for all APRN programs but has particularly affected neonatal APRN programs and resulted in decreased student acceptance and enrollment.1 A recent study published in ScienceDaily reported that there is capacity in NNP programs but there is decreased enrollment because of a perception that there are insufficient openings in the field.6 Approximately 25% of the NNP programs surveyed have closed in recent years because of difficulty in hiring or retaining faculty. In addition, NNP programs face difficulties securing or maintaining clinical placement sites because they compete with family nurse practitioner and physician assistant programs for limited preceptor openings.6 LeFlore and Thomas7 identified additional educational barriers such as aging faculty and noncompetitive faculty salaries, tenure, and workload that contribute to faculty shortages in all types of APRN programs. They suggest a shift from the competency model based on acquiring clinical hours, credits, and a one-on-one apprenticeship to a newer model using simulation, academic-practice partnerships, case studies, virtual patients, team-based care expectations, and simulated clinical experiences within an interdisciplinary environment to educate future nurse practitioners.Professional nursing organizations and schools of nursing are encouraged to advocate for regulation changes within the US Department of Education to overcome these barriers. APRNs are encouraged to engage with NNP programs to increase their recruitment efforts, increase the number of NNP programs, and resolve the shortage of faculty and preceptors for NNP students. New programs are encouraged to develop collaborative agreements with existing programs.8 Alternatively, postgraduate NP preparation could be streamlined for nurse practitioners certified in other population areas such as pediatric or family.1The average age of NNPs responding to the NNP workforce survey in 2016 was 49 years.2 Thirty-two percent of respondents were age 55 or older.2 This contrasts with the average age of 46 years in the 2006 survey.2 Eighty-two percent of NNP respondents work full time, with 58% working in level III and 35% working in level IV neonatal intensive care units.2 Respondents reported that the following factors influence job satisfaction, recruitment, and retention: autonomy, salary, workload, shift work, respect for the role, and inclusion in decision-making.2 Currently, experienced NNPs have many late-career options, such as early retirement, academia, administration, and home nursing. To encourage experienced NNPs to remain in the workforce, we must appeal to their values. The NNP workforce survey found that NNPs value the following aspects of a compensation package: work/life balance, salary, retirement/health benefits, paid time off/vacation, reimbursement for malpractice insurance, paid sick leave, overtime pay, holiday pay, and alignment of actual work hours with expected work hours.2NNPs have many barriers to practice including a lack of consistency in practice regulations across states, lack of standardization regarding autonomous practice and prescriptive authority for controlled substances, institutional restrictions related to privileging and credentialing, and lost revenue caused by the need for physician oversight for some billing. In some institutions, APRN care may be treated as an expense rather than a revenue source. Institutional, practice, or regulatory barriers may prohibit APRNs from receiving reimbursement for direct patient care from third-party payers.A shift to using a neonatologist/NNP staffing model is resulting in increased NNP vacancies.3 A licensure compact for APRNs approved in May 2015 by the National Council of State Boards of Nursing and implemented in several states has made it easier for APRNs to work across state boundaries.9 Full implementation of the APRN consensus model in all states would ensure uniform education, licensure, certification, and accreditation of all APRNs.10 Allowing APRNs to practice to the full extent of their preparation should promote consistency in reimbursement laws.10 Moving toward full practice authority within interprofessional teams that are focused on patient outcomes and inclusive of evidence-based practice should allow the needed time for outcomes-based research, quality initiatives, and continuing education.11 This activity will measure and validate APRN practice in the areas of cost-effectiveness, quality of care, efficiency, and outcomes.Having reached the age where I am the statistic reported in the NNP workforce survey, and as I think about the current APRN workforce, I am struck by the reality that succession planning is not something we think about as nurses and certainly not as APRNs. While reading about succession, I came across a passage that resonated with me. Succession planning was described as a hallmark of a true leader.12 The effective leader was described as a person who could step out of water and not leave a ripple. The time for ripples is when a leader is trying to influence the team to achieve their maximum potential, not when a leader is leaving a job.12 Succession planning is defined as a strategy for identifying and developing future leaders. Succession plans are used to address the inevitable changes that occur as employees resign, retire, get sick, get fired, or die. In the business world, succession planning is done to be prepared for all contingencies. Our patients deserve the same thoughtful planning.Leadership skills can be learned and are acquired with the right mentor. It takes time to find and prepare promising candidates; current APRNs should always be aware of the potential in their coworkers to be a great APRN. Keep an open mind about all colleagues; avoid disregarding any promising employee. Look for those staff members who display the necessary skills to become a thriving NNP. Once you identify these employees, offer regular feedback on their job performance. Provide training for peak performers including offers of mentoring, job shadowing and training, development of new skills, or refinement of existing skills. Leaders who are creating a succession plan need to make their vision known. Advertise that you are looking for a successor and what skills you are seeking. Create a vision of what your successor will look like.We can wait for educators, federal regulators, third-party payers, or others to create the environment for nurses to consider advanced practice, or we, as advanced practice nurses, can groom our own successors. We can mentor, precept, assist with networking, and teach, and we can help NNP programs in our area thrive. NNPs who have a passion for their work are the best advertisement to recruit more neonatal nurses into this exciting and expanding field of practice.

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